Social Science & Medicine 53 (2001) 1397–1411
Voluntary counseling and testing for couples: a high-leverage
intervention for HIV/AIDS prevention in sub-Saharan Africa
Thomas M. Painter*
Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention, Division of HIV/AIDS Prevention-
Surveillance and Epidemiology, Prevention Services Research Branch, Mailstop E-46, 1600 Clifton Road, N.E. Atlanta, GA 30333, USA
Most HIV infections in sub-Saharan Africa occur during heterosexual intercourse between persons in couple
relationships. Women who are infected by HIV seropositive partners risk infecting their infants in turn. Despite their
salience as social contexts for sexual activity and HIV infection, couple relationships have not been given adequate
attention by social/behavioral research in sub-Saharan Africa. Increasingly studies point to the value of voluntary HIV
counseling and testing (VCT) as a HIV prevention tool. Studies in Africa frequently report that VCT is associated with
reduced risk behaviors and lower rates of seroconversion among HIV serodiscordant couples. Many of these studies
point out that VCT has considerable potential for HIV prevention among other heterosexual couples, and recommend
that VCT for couples be practiced more widely in Africa. However, follow-up in the area of VCT for couples has been
extremely limited. Thus, current understandings from social/behavioral research on how couples in sub-Saharan Africa
manage HIV risks as well as HIV prevention interventions to support couples’ HIV prevention efforts have remained
underdeveloped. It appears that important opportunities are being missed for preventing HIV infection, be it by
heterosexual transmission or mother-to-child HIV transmission by mothers who have been infected by their partners.
Based on an overview of documentation on VCT in sub-Saharan Africa, this paper proposes that increased attention to
couples-focused VCT provides a high-leverage HIV prevention intervention for African countries. The second half of
the paper indicates areas where VCT needs to be strengthened, particularly with respect to couples. It also identifies
areas where applied social/behavioral research is needed to improve knowledge about how couples in sub-Saharan
Africa deal with the risks of HIV infection. Published by Elsevier Science Ltd.
Keywords: Africa; Couples; Gender; Heterosexual HIV transmission; HIV- prevention; Voluntary counseling and testing (VCT);
HIV/AIDS in sub-Saharan Africa
23.3 million persons in sub-Saharan Africa were living
with HIV infection or AIDS by the end of 1999,
accounting for nearly 70% of the estimated 33.6 million
individuals living with HIV/AIDS worldwide (UN-
AIDS/WHO, 1999). The vast majority of these persons
were infected during heterosexual intercourse (Allen
et al., 1992b; Berkley, 1994). During 1999 nearly 90% of
the 571,000 children born or infected with HIV-1
through breast-feeding were living in sub-Saharan
Africa. The mothers of these infants were infected
during heterosexual intercourse (UNAIDS/WHO, 1999).
Couples and heterosexual transmission of HIV infection
Couple relationships of varying stability and longevity
account for most heterosexual activity between indivi-
duals in Sub-Saharan Africa (Caldwell, Caldwell, &
Quiggin, 1994; Carael et al., 1988; Carael, Cleland, &
Ingham, 1994; Carael, Cleland, Deheneffe, Ferry, &
Ingham, 1995; Heise & Elias, 1995; Larson, 1989;
Morris & Kretzschmar, 1997; Orubuloye, Caldwell, &
E-mail address: firstname.lastname@example.org (T.M. Painter).
*Tel.: +1-404-639-6113; fax: +1-404-639-4268/0910/6127.
0277-9536/01/$-see front matter Published by Elsevier Science Ltd.
PII: S 0277 -9536(00 )0 0427-5
Caldwell, 1992, 1993). In high prevalence areas of
Africa, cohabiting couples make up a large proportion
of groups at risk from HIV infection. The greatest HIV
risk for women in these couples is their husband or
regular partner (de Zoysa, Sweat, & Denison, 1996;
Heise & Elias, 1995; King, Allen, Serufilira, Karita, &
Van de Perre, 1993; McKenna et al., 1997).
Insufficient social–behavioral knowledge about HIV risk
and risk management by couples
Despite the salience of couple relationships as
contexts where social–behavioral, economic and other
situational factors shape sexual relations and the risks of
infection from HIV and other sexually transmitted
diseases (STDs), current understandings of HIV risk
and risk prevention efforts by persons in couple
relationships in sub-Saharan Africa are unsatisfactory
(Baingana, Choi, Barrett, Bayansi, & Hearst, 1995;
DeZoysa et al., 1996; Ezeh, 1993; Hassoum, 1996;
McGrath et al., 1993; Seeley et al., 1994). Orubuloye and
others have characterized as ‘‘extraordinary’’ the lack of
research on the degree to which women (and by
implication, men) in couple relationships in sub-Saharan
Africa can control and modify their sexual relations with
partners (Orubuloye et al., 1993; cf. Ezeh, 1993; Van der
Straten, Kin, Grinstead, Serufilira, & Allen, 1995).
Few presentations have been made on couple-focused
research or prevention interventions at recent annual
international HIV/AIDS conferences (cf. 12th World
AIDS Conference, 1998; XIth International Conference
on AIDS & STDs in Africa, 1999; XIII International
AIDS Conference, 2000). The lack of attention given to
couples-related issues at international fora is both an
indicator of and contributing factor to persistent gaps in
current understandings about how couples deal with
HIV risk in developing areas of the world.
Given an inadequate knowledge base about social–
behavioral issues and about the dynamics of couple
relationships in particular, it may not be surprising that
HIV prevention interventions for couples sub-Saharan
Africa are rare indeed (Baingana, Choi, Barrett,
Bayansi, & Hearst, 1995; de Zoysa et al., 1995; de
Zoysa, Sweat, & Denison, 1996; Desclaux & Raynaut,
1997; O’Reilly & Piot, 1996).
Current approaches to HIV prevention in sub-Saharan
Africa: how responsive to couples’ needs?
Broad-based HIV/AIDS information programs, be
they referred to as Information Education and Com-
munication (IEC) or Communications for Behavior
Change, and which use the electronic and (to a lesser
extent) printed media to promote HIV/AIDS awareness
and behavior change, have been common in sub-
Saharan Africa since the mid-1980s. Typically these
programs are directed toward an undifferentiated public
or categories of individuals that are identified as more
inclined to engage in higher-risk sexual behaviors.
Messages may, for example, encourage men as members
of a gender category to use condoms with non-regular
sexual partners, particularly female sex workers. Media
messages are less likely to address details of condom use
with the mens’ wives or other regular sexual partners.
Media programs that depict two heterosexual partners
together are more often concerned with the technicalities
of safe sex (proper condom use) than with processes of
communication and negotiation (or lack thereof) that
affect HIV risk and prevention efforts by couples.
While media-based programs may occasionally de-
scribe voluntary counseling and testing, they infre-
quently provide specific messages for couples and are
characterized by unidirectional information flow. Mem-
bers of mass media audiences rarely have opportunities
to ask questions or obtain clarification on issues
pertinent to their particular situations. While media-
based efforts by national AIDS programs in sub-
Saharan Africa have contributed to increased levels of
HIV/AIDS awareness and some improvements in
knowledge about HIV/AIDS, their impact on behavior
change outside a few high-risk categories (e.g., female
sex workers) has been much more modest (Cohen &
Trussel, 1996). Only two countries in Africa } Uganda
and Senegal } are often cited as examples of success
with broader-based behavioral changes leading to a
decline in HIV seroprevalence levels. Uganda, it must be
noted, has received large amounts of international
financial and technical support for its HIV/AIDS
prevention efforts since the early 1990s.
The small but gradually increasing number of free-
standing VCT centers and the even smaller number of
health facilities in sub-Saharan Africa where VCT is
offered, represent the other extreme from media-based
programs for communicating HIV/AIDS prevention
information. Rather than targeting undifferentiated
publics with a one-way flow of information, VCT
facilities provide health workers with opportunities both
to provide clients with information, including informa-
tion on their serostatus if they wish, to work with clients
on ways of using the information, and elicit questions
and discussion to ensure that clients understand
information that is provided.
However, VCT facilities in sub-Saharan Africa are
infrequently attuned to couples’ needs and few couples
present together for VCT. Most VCT facilities address
individual clients who request HIV testing (free-standing
T.M. Painter / Social Science & Medicine 53 (2001) 1397–14111398
VCT centers) and who in some cases (e.g., Uganda)
are willing to pay fees for VCT, or who are invited
(at urban antenatal clinics or blood banks) to be
tested for HIV. In the case of antenatal clinics in
sub-Saharan Africa, women frequent the facilities
primarilyfor medical consultations,
women do not know about VCT testing opportunities,
where available, before arriving at clinic settings,
they may be surprised by the offer of a HIV test
and refuse on the spot or tell counselors that they wish
to postpone their decisions, often amounting to a
deferred refusal (Cartoux et al., 1998; Diaby et al.,
1996; Painter et al., 1998).
In these settings VCT clients interact individually with
counseling staff. Clients are invited to rapidly think
about HIV/AIDS and consider having a HIV test, but
their discussions are disarticulated from the everyday
realities of communicating, much less negotiating,
protective actions with their partners who are absent
from the VCT session.
After the VCT session is over, however, many
individual VCT clients return to partners in couple
relationships. Despite their non-involvement in pre-test
decision making, these absent partners can importantly
affect the decisions that VCT clients make: to accept or
refuse HIV testing, to return or not for test results and
post-test counseling, to disclose test decisions and test
results, and for women who find that they are infected
with HIV, or to enroll where available, in short course
antiretroviral therapies (e.g., zidovudine, nevirapine) to
prevent mother-to-child transmission of HIV infection
Partners also affect VCT clients’ ability to follow
through on intentions and decisions made during VCT
sessions. Effective protective action against HIV/STD
infection within couple relationships requires commu-
nication, agreement, and above all, cooperation between
couple members. The obstacles to carrying out intended
protective actions can be particularly daunting for
women in couple relationships. The responses that
women encounter to their prevention efforts with male
partners may vary from silence (indifferent to cool), to
resistance and non-cooperation, to threats and physical
violence. While these factors affect protective actions
against HIV infection, they have not been given much
attention by social/behavioral research and prevention
interventions in sub-Saharan Africa and other world
areas (Caldwell et al., 1994; Chaima & Zimba, 1998;
Hassoum, 1996; Heise & Elias, 1995; M’Pele, Lallemant-
LeCoeur, & Lallemant, 1994; Mullick, Abdool Karim,
& Morar, 1998; Ulin, 1992; cf. Bajos, 1997; Cupach &
Metts, 1991; Edgar et al., 1992; Moore & Padian, 1993;
Moore et al., 1995). Very little is known about the socio-
sexual lives of couples in sub-Saharan Africa after one
or both members has been tested for HIV.
The unsatisfactory picture we have of how VCT
clients and their partners carry out HIV/STD risk
management may result from a methodological bias of
VCT programs and studies that rely too much on
individual VCT clients, particularly women, as sources
of information about both their own and their partners’
reasoning and actions.
The AIDS Information Centre (AIC) in Uganda is
one exception to the current emphasis on individual
counseling by VCT programs in Africa. While the AIC’s
principal focus has been one of providing VCT to
individual clients, the Centre’s clientele has changed.
The number of persons requesting VCT as couples has
steadily increased from 8% of all clients in 1992 to
nearly a third currently. Nearly 80% of these couples
request HIV testing as a kind of premarital screening
process, described as ‘‘planning for marriage’’ (Baryar-
ama et al., 1996; Turyagyenda, 2000). Several factors
help explain the increased demand for couples’ VCT,
among them a national HIV/AIDS policy in Uganda
that has promoted behavior change and open discussion
of AIDS-related issues since the 1980s, resulting in
greater willingness by couples to be tested together, AIC
promotions that target couples with a ‘‘two-for-one’’
approach, and pressures from young couples’ families
and churches to be tested for HIV before marriage. If
test results show that one partner is infected, the
relationship often terminates shortly thereafter (Turya-
gyenda et al., 1998). In response to the increased
demand by couples for VCT, AIC is developing
approaches to VCT and post-test follow-up that are
more attuned to couples’ situations and needs (Alwano-
Edyegu et al., 1998).
Outside Uganda, the development of capacity for
VCT with couples, be they couples-in-the-making or
established couples, has been slow. Retooling of VCT
approaches will take time and resources but it is needed
to better address couples and a unique and important
opportunity for HIV/AIDS prevention in Africa. VCT
for couples includes two, possibly more social interac-
tions between counselors and couple members individu-
ally and together to discuss HIV risks and feasible
approaches to prevention. VCT for couples thus has the
potential for incorporating sexual partners that are
absent during VCT for individuals, and addressing
obstacles to HIV prevention practice.
Alternatively, counseling staff may request or encou-
rage individual clients to ask or encourage partners to be
tested for HIV. Experience in sub-Saharan Africa
indicates that this approach has been largely unsuccess-
ful, and women encounter particular difficulties when
they try to convince partners to be tested for HIV. Test
rates for male partners of well under 5% have been
reported in Co ˆ te d’Ivoire (Ba et al., 1995), Democratic
Republic of Congo (Heyward et al., 1993), Mali (Le
Palec, 1994), Rwanda (Ladner et al., 1996), and
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1399
Zimbabwe (Dube, Machekano, McFerland, & Mandel,
Evidence from studies and prevention interventions
VCT studies and interventions from 1990 to 1997
VCT has received considerable scrutiny in the
scientific literature during the 1990s. Reviews (e.g.,
Beardsell, 1994; Beardsell & Coyle, 1996; Campbell
et al., 1997; Choi & Coates, 1994; Gerber, Campbell,
Dillon, & Holtgrave, 1994; Higgins et al., 1991; Irwin,
Valdiserri, & Holmberg, 1996; Oakley, Fullerton, &
Holland, 1995; Wolitski, MacGowan, Higgins, &
Jorgensen, 1997) and studies in African and non-African
settings have assessed the effectiveness of VCT in
reducing risk behaviors and occasionally rates of HIV
seroconversion among VCT recipients (e.g., Allen et al.,
1992a,b; De Vincenzi, 1994; Feldbulm, 1991; Kamenga
et al., 1991; Moore et al., 1991; Moore et al., 1993;
Muller et al., 1992; Padian, O’Brien, Chang, Glass, &
Francis, 1993; Pickering, Quigley, Pepin, Todd, &
Wilkins 1993; Temmerman et al., 1990; van der Straten
et al., 1995).
Studies report mixed results in terms of reduced risk
behaviors and HIV infection rates and VCT seems to
have little effect on pregnancy decisions by HIV-infected
women (and importantly, their partners), but substantial
risk-reduction and lower rates of seroconversion were
often reported for HIV serodiscordant couples, particu-
larly in couples where both partners know their
serostatus. Behavior changes among discordant couples
were not uniform, however, pointing to gender-asso-
ciated power differences within couple relationships.
Condom use in discordant couples in sub-Saharan
Africa after VCT, for example, was more frequent and
consistent in couples where men were HIV seronegative
(Kamenga et al., 1991; Maposhere et al., 1996;
Serwadda, Gray, Sewankambo, & Wawer, 1994; Ser-
wadda et al., 1995; van der Straten et al., 1995).
Debates over VCT during much of the 1990s
concerned the appropriateness of VCT for developing
country settings as well as its effectiveness. International
organizations and African health ministries were reticent
because of doubts about the cost-effectiveness of VCT in
countries where access to basic health services is limited.
Per-capita health expenditures in sub-Saharan Africa are
among the lowest in the world.
Nevertheless, evidence concerning the benefits of VCT
continued to accumulate during the 1990s from studies
in several African countries, among them, the Demo-
cratic Republic of Congo (Heyward et al., 1993; Jingu
et al., 1990; Jingu, Mbuyi, Ndilu, Assina, & Musingayi,
1993; Kamenga et al., 1991); Congo (M’Pele, Lallemant-
Lecoeur, Lallemant, & Samba, 1991); Rwanda (Allen
et al., 1992a,b; Keogh, Allen, Almedal, & Temahagili,
1994; King et al., 1993; Ladner et al., 1996; van der
Straten et al., 1995); Uganda (AIDS Information
Centre, 1994; Lainjo, Wawer, Lutalo, Sewankambo, &
Kelly, 1994; Moore et al., 1993; M’Pele et al., 1994;
Muller et al., 1992; Serwadda et al., 1995); and Zambia
(Feldblum, Hira, Godwin, Kamanga, & Mukelabai,
1992; McKenna et al., 1997). Similar to findings often
reported elsewhere, many of these studies reported
significant reductions of risk behavior, and when
biomedical outcomes are recorded, lower rates of
seroconversion in HIV serodiscordant couples following
VCT. They frequently recommended as well that VCT
for couples should be practiced more widely in sub-
Saharan Africa. A more detailed review of the scientific
literature on VCT during this period is beyond the scope
of this paper. Readers are referred to the sources cited
immediately above for additional details.
More recent VCT studies
The most convincing evidence yet about the effective-
ness of VCT was reported in the late 1990s from studies
in Africa and the United States. Randomized controlled
trial studies of counseling and testing in Kenya,
Tanzania, Trinidad (Coates et al., 1998; Gregorich,
Kamenga, Sangiwa, Furlonge, & Balmer, 1998; Sangi-
wa, Balmer, Furlonge, Grinstead, & Kamenga, 1998,
The Voluntary HIV-1 Counseling and Testing Efficacy
Group, 2000) and the US (Kamb et al., 1998) reported
lower incidence of STDs and longer periods of HIV/
STD risk reduction among persons receiving VCT than
among persons who received HIV/AIDS prevention
information using health education formats.
Study results in the early 1990s indicated that VCT
provided net economic benefits in developed country
settings (e.g., Holtgrave, Valdiserri, Gerber, & Hinman,
1993), but cost-effectiveness analysis was not applied to
developing country settings until recently. The multi-site
study in Kenya and Tanzania also assessed the cost-
effectiveness of VCT. Once again, the results were
supportive of VCT as a prevention intervention in
resource-constrained settings. Data published in 2000
show that 1104 HIV-1 infections were averted in Kenya
at a cost of $249 per averted infection and that 895
infections were averted in Tanzania at a cost of $346 per
averted infection. The infection costs of $12.77 and
$17.70 per disability-adjusted life-year saved in Kenya
and Tanzania respectively, compare favorably with costs
of other interventions (Sweat et al. 2000; cf. Van de
Perre, 2000). VCT was found to be most cost effective
for HIV-1 seropositive persons and for persons who
received VCT as couples.
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1400
A favorable moment for couples’ VCT as a component of
HIV/AIDS prevention strategies in sub-Saharan Africa?
Accumulating evidence that VCT works and is cost-
Studies in sub-Saharan Africa during the 1990s
produced evidence indicating, albeit somewhat incon-
sistently, that VCT can be effective as a HIV-prevention
tool, particularly when members of couples participated
together in the VCT process. Evidence of VCT-induced
HIV risk reductions and rates of HIV seroconversion
was particularly strong in the case of HIV serodiscor-
dant couples. Regardless of study results, however,
investigators were nearly unanimous in noting that VCT
for couples may be a particularly powerful HIV
prevention tool. Researchers very often recommended
further studies of couples-focused VCT and called for
the increased use of VCT for couples in sub-Saharan
Africa. More recent results from randomized clinical
trial studies in Kenya and Tanzania have provided
additional evidence that VCT is an effective and
appropriate prevention intervention in the resource-
constrained situations typical of countries in sub-
Greater international support for VCT
The political climate also became more supportive of
VCT in developing country settings during the late
1990s. UNAIDS and other international organizations
engaged in HIV/AIDS prevention (e.g., the United
States Agency for International Development [USAID],
the World Bank) have expressed strong support for
making VCT available to populations in developing
countries (UNAIDS, 1998; The World Bank, 1999).
Intervention research not directly focused on VCT
efficacy, but which included VCT as a component, has
also contributed to a change from widespread scepticism
to increasing support among international agencies for
VCT as a prevention tool in Africa. In 1998 the results
of randomized clinical trials in Thailand and Co ˆ te
d’Ivoire demonstrated that MTCT of HIV-1 can be
reduced by 50% among non-breast-feeding Thai women
and by nearly one-third among breast-feeding women in
Co ˆ te d’Ivoire (Shaffer et al., 1999; Wiktor et al., 1999).
Very shortly thereafter, UNAIDS and UNICEF in-
itiated several pilot prevention interventions in sub-
Saharan Africa with a view toward upscaling of MTCT
prevention after reality checks in typical health care
Preventing mother-to-child HIV transmission requires
HIV testing and counseling of pregnant women. Because
antenatal clinic settings cover only individual pregnant
women who seek consultations for healthy babies,
meeting the challenge of protecting African infants from
HIV infection will require better protection of women
from heterosexual HIV infection. Effective prevention
requires cooperation from women’s partners. This gives
added urgency to the need for health facility-based VCT
programs in sub-Saharan Africa that incorporate
women’s sexual partners through targeted recruiting
efforts and community outreach to couples (Diaby et al.,
2000; Painter et al., 1999, 2000).
A favorable moment for VCT in sub-Saharan Africa?
The accumulation of evidence about the efficacy, cost-
effectiveness and the acceptability of VCT in sub-
Saharan Africa, and the increased awareness of the
prevention potential of VCT for couples suggest that
HIV/AIDS prevention has reached a critical } socio-
logical } juncture. In effect, by providing high-quality
VCT and associated support for couples, HIV/AIDS
prevention is returning full-circle to the most typical and
widespread socio-cultural setting for heterosexual HIV
infections in sub-Saharan Africa: couple relationships.
Rather than simply addressing undifferentiated publics,
or individual VCT clients in the absence of their sexual
partners, the stage is set for VCT work with couple
members together and in relation to the roles and
responsibilities and the opportunities and constraints
that make up everyday life for couples, and which affect
HIV risk and risk prevention.
Assuming for the moment that this is indeed a
propitious moment for HIV/AIDS prevention in sub-
Saharan Africa, what should be done to capitalize on the
opportunities it presents? The next section of the paper
will address these issues by indicating several areas
where VCT needs to be strengthened for work with
couples, and by identifying areas where applied social/
behavioral research is needed to improve knowledge
about how couples in sub-Saharan Africa deal with the
risks of HIV infection. The following remarks are based
on experiences described in sources cited earlier and on
the author’s experiences with applied research related to
implementation of VCT programs at free-standing VCT
facilities and in mother–child clinic settings in Uganda
and Co ˆ te d’Ivoire, respectively (Campbell et al., 2000;
Diaby et al., 2000; Painter, 1996; Painter et al., 1998,
1999, 2000). Clearly, many of the recommendations
about areas where VCT needs to be strengthened for
couples also apply to VCT in general. Likewise, the
areas that have been identified as urgently needing more
social/behavioral research overlap to a degree with needs
for innovative and improved approaches to providing
VCT in Africa. In practice, a much stronger linkage is
needed between the generation of knowledge by applied
and operational social/behavioral research and VCT
interventions for couples.
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1401
What is to be done?
Strengthen VCT procedures, staff capacity &
Target couples in VCT recruitment efforts. The
prevention potential of VCT for couples in Africa
can be realized only if more couples learn about and
gain access to VCT. Components of a more
specialized VCT package for couples would include:
*Frequent, clear and accurate media-based informa-
tion programs using multiple languages are needed to
increase access to information on VCT, with
particular attention to the importance of VCT for
mother–child HIV transmission.
*Community outreach to couples in areas surrounding
VCT facilities. This interactive approach is needed as
a follow-on and complement to media-based infor-
mation programs. Specific approaches need to be
developed through pilot efforts and operational
research. They would aim to optimize opportunities
for contacts by trained outreach workers and
counseling staff (both of whom could possibly be
recruited from among HIV seropositive men and
women and couples that have coped successfully
after VCT and receiving HIV seropositive test
results) with couple members together and individu-
ally to ensure that discussion and queries occur and
that specific question are answered. Recent and
(McKenna et al., 1997) and Uganda (Alwano-
Edyegu et al., 1998) respectively, to recruit and better
address couples’ needs, provide useful lessons for
couple recruitment efforts elsewhere in sub-Saharan
*More specialized topics must be covered during
group information sessions when used, when couples
arrive at VCT facilities, during pre- and post-test
counseling sessions and during facility- or commu-
nity-based follow-up contacts with couples after
VCT. Coverage would require that counseling staff
address a range of possible topics as appropriate
during the VCT process. This should not be done in a
lock-step progression, but be based on the opportu-
nities and needs that occur during encounters with
couple members together and separately. Coverage
would combine the provision of information with
exchange and discussion. More specialized informa-
tion would include:
The importance and contribution to HIV risk
reduction of greater openness and communica-
tion between couple members about:
– HIV risk and prevention knowledge.
Their own risk backgrounds and actions.
Prevention options and obstacles they face
with risk reduction efforts during sexual
Fears associated with HIV and the diffi-
culties associated with public knowledge of
one’s participation in HIV prevention
Disclosure of HIV test decisions and
results, of intentions or the wish to engage
in prevention actions such as using con-
doms, VCT, or in the case of HIV
seropositive women, antiretroviral therapy
to reduce MTCT.
The importance of efforts to reduce and
avoid conflict and violence related to
prevention efforts or to the disclosure to
partners of information about serostatus.
Approaches to developing realistic and
acceptable HIV prevention strategies with-
in couples, detailing roles and responsibil-
ities of couple members, thereby better
equipping } and empowering } couples
to work together rather than at cross-
purposes for HIV prevention.
A focus on the importance of cooperation
by couple members for successful efforts to
protect themselves (and their outside sex-
ual partners if these external relationships
appear to be non-negotiable) and their
children from HIV infection.
*Counseling for couple members both individually
and together, during pre- and post-test periods.
*Multiple and variable post-test follow-up of couples
during the time after post-test counseling to better
understand couple coping, identify difficulties and
successes, provide couples with support or referrals,
and further strengthen the capacity of VCT facilities
for work with couples.
*Community-based support for couples, including con-
fidential support groups for couple members, together
and separately, organized according to gender, seros-
tatus, status of the couple relationship, etc.
*Stronger post-test support for coping and HIV risk
management is particularly important for HIV
seropositive women in couples, given their social
vulnerability, particularly to being ejected by part-
ners from couple relationships, and their frequently
reduced access to sources of material and moral
support. For purposes of identifying opportunities
for providing support to HIV+ women, VCT
facilities need to work with women in a continuum
of couple configurations:
Ongoing couple relationships where male part-
ners are supportive or unsupportive following
disclosure of the woman’s HIV+ serostatus.
T.M. Painter / Social Science & Medicine 53 (2001) 1397–14111402
Ongoing couples where women do not or
cannot disclose their serostatus to partners.
Couple relationships that have been seriously
disrupted or destroyed due to prior conflicts
related to sexual issues or following disclosure
of the woman’s HIV+ serostatus.
*Periodic assessments and strengthening of key
components at VCT facilities, including:
Counseling staff skills and demeanor to ensure
that couples (and all other clients) are well-
received by VCT staff and feel that counseling
staff are genuinely interested and supportive of
their situations as couples, and also have the
expertise to deal with issues of couple commu-
nications and risk reduction in couple settings.
The configuration of space to ensure that
confidentiality is assured for comfortable, effec-
tive work with all clients, including couple
members together and separately.
Associate VCT with a broader range of health services.
Increased international interest in and support for VCT
in sub-Saharan Africa is salutary, however successfully
addressing the severe social stigma associated with HIV/
AIDS and increasing the acceptability of VCT as a HIV
prevention tool will require that VCT increasingly be
made available as part of a broader range of health
services that focus on mother–child, reproductive, and
family health issues (Cartoux et al., 1998; Dabis, Newell,
Fransen, Saba, & De Vincenzi, 1998).
Concern for a broader range of mother–child health
issues, particularly protecting infants whose survival is
critical for socio-cultural continuity between generations
may give heterosexual HIV prevention a salience and
acceptability greater than current levels that result from
prevention messages targeted largely to undifferentiated
publics or individual VCT clients. Currently, one of the
trade-offs that contribute a great deal to consistently low
rates of condom use in sub-Saharan African involves
(particularly, but not only for men) foregoing some
sexual pleasure to prevent HIV infection. If the tradeoff
} or the stakes } were more widely redefined in Africa
as one of protecting children } the next generation }
from HIV/AIDS, condoms and diminished sexual
pleasure may become more acceptable.
To date there is very little evidence that HIV
prevention programs in sub-Saharan Africa are linking
heterosexual and mother-to-child HIV transmission in
this way as they promote HIV prevention and VCT.
Success with this approach will require that more
prevention work be done with couples and with the
larger families and kinship relationships of which they
are members. The stakes of HIV/AIDS prevention in
sub-Saharan Africa involve more than preferences by
individuals and couples. These factors need to be
brought into the prevention picture and examined in
terms of the opportunities they offer HIV prevention
efforts as well as the obstacles they may represent.
While the potential for increasing access to VCT by
embedding it within a range of health services is
particularly important for hospitals and mother–child
clinics, free-standing VCT centers in high prevalence
areas also stand to gain from increased client response,
hence increased acceptability and effectiveness of VCT,
by broadening the scope of diagnostic, counseling,
treatment, care and referral options they offer. Here,
once again, more comprehensive service programs that
incorporate VCT need to target households and couples
by a combination of outreach and delivery of services
that are sufficiently effective and discrete that both
members of couples will be encouraged to benefit.
Integrating VCT with other health services can serve
multiple objectives, including the reduction of social
stigma, but significant progress with destigmatizing
HIV/AIDS will require more robust efforts at the
highest levels of African government. This will be
possible only if African heads of state spearhead and
sustain efforts to create opportunities in civil society
where individuals and couples perceive social and moral
support for their efforts to ‘‘do the right thing’’: protect
themselves, their sexual partners, and their infants from
Better assessment of VCT processes and outcomes
Assess outcomes. Social–psychological, behavioral
and biomedical outcomes of VCT programs need to be
assessed more consistently and rigorously. Program
evaluations are critical to judging impact and success,
but are often accorded lower priority operationally
because of the primacy that VCT facilities give to
serving clients. It’s noteworthy that much of the debate
over VCT effectiveness during the 1990s was fueled by a
lack of solid evaluation data and little consensus on the
evaluative criteria used during program assessments.
Improved program assessments will require more
detailed follow-up of VCT clients as they and their
partners cope with knowledge of serostatus, HIV risk
and risk reduction during the time that follows HIV
testing. Given the realities of post-HIV test coping and
HIV risk management, and the need to tailor counseling
and support services to couples’ needs, follow-up needs
to focus more on specific couple profiles. For example,
relationship longevity and stability, marital status,
serostatus (HIV+ discordant, HIV+ concordant or
high and low risk HIV? negative), members’ HIV
infection risk profiles, and sources and quality of post-
test support from family, friends, etc., are among the
factors that require attention when looking at post-test
coping and HIV risk management by couples.
These attributes of couples and their members affect
the opportunities and constraints that couples in sub-
Saharan Africa face when they deal with HIV risk and
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1403
risk reduction. Very little is known about the effects of
these factors on HIV risk management by couples.
Effective VCT for couples requires that these factors be
better understood and addressed by VCT programs for
The use of qualitative data analysis and ethnographic
methods can be particularly helpful for efforts to better
understand different levels of success by couples with
coping and HIV risk management over time (Painter
et al., 2000).
Develop realistic criteria for assessing VCT interven-
tions. Broadly accessible evaluative criteria for guiding
and assessing VCT quality assurance need to be
developed and disseminated, both nationally and within
and across the Anglophone, Francophone and Luso-
phone cultures of public health organization and
procedures that shape service delivery, including VCT
and other prevention interventions in sub-Saharan
African countries. Evaluative criteria need to be broadly
comparable across typical VCT settings, but also need to
take into account localized resource constraints, prac-
tices and features of the settings where health services
are delivered. VCT guidelines issued by UNAIDS and
other international organizations are useful as points of
reference, but there is a continuing need for reality
checks against local conditions and possibilities. The
verification and needed modifications in program
approaches must be based on the results of intervention
assessments and applied/operational social/behavioral
research. There is no single answer to the question,
‘‘What constitutes best practice for VCT service delivery
in sub-Saharan Africa?’’
Government policies must be supportive of HIV/AIDS
Commitment at the highest levels of government is
(still) needed for successful HIV/AIDS prevention in sub-
Saharan Africa. Reports of HIV prevention success from
countries in Africa such as Senegal and Uganda where
governments have joined forces with broader constitu-
[NGOs] and religious leaders (UNAIDS/WHO, 1998)
are encouraging. Heads of state and other important
leaders in both countries have provided high-level, high-
profile support of HIV prevention efforts.
However, session after session at the XIth Interna-
tional Conference on AIDS and STDs in Lusaka,
Zambia in 1999 made it abundantly clear that Uganda
and Senegal are } and may long remain } exceptional
cases in sub-Saharan Africa (cf. Caldwell, 1999). The
Lusaka conference was characterized by a palpable
sense of disappointment and frustration among partici-
pants over the lack of commitment by African leaders to
combating HIV/AIDS despite considerable hoopla over
these issues at the international conference 2 years
earlier in Abidjan, Co ˆ te d’Ivoire.
African heads of state, prime ministers, ministers of
health, and other key lay and religious leaders at
multiple levels must play a more supportive role in
creating national and local environments that empower
HIV prevention efforts by persons in couple relation-
ships. Just as media-, community-, and facility-based
programs need to tailor their messages and support
services for couples, so African political and public
health leaders need to speak more often and more
convincingly about the importance of HIV prevention,
including VCT, for couples. Consider the potential
impact of a mini-series on TV and radio that follows an
African head of state and his wife through the steps of
VCT for couples: considering the experience, encounter-
ing and coping with it, and extolling its value for the
many couples that are tuned in. It can be predicted that
the news of a program like this would spread rapidly,
even among persons without easy access the media,
drawing more persons to the program and to facilities
where VCT is offered.
Information on VCT must be widely accessible to
couples. Thanks to widespread information programs,
HIV/AIDS awareness has increased considerably in sub-
Saharan African countries since the mid-1980s. Despite
these efforts, presentations at international conferences
continue to report widespread and persistent erroneous
beliefs among persons surveyed about how HIV is
transmitted and prevented.
National HIV/AIDS information programs and their
international partners must provide their publics with
accurate, up-to-date information. But how many na-
tional HIV/AIDS program in sub-Saharan Africa have
incorporated prevention information based on recent
developments including syndromic management of
sexually transmitted infections (STIs), VCT, including
the added value of VCT for couples, more rapid and less
invasive HIV testing technologies, and prevention of
mother-to-child HIV transmission? Most likely, not
many. Information on and access to these and other
public health developments must be made widely
accessible if Africans are to genuinely benefit from new
screening, prevention and treatment options that be-
The lack of synchronization between new treatment
options and public access to prevention information can
create obstacles to prevention. Among the HIV-1
seropositive pregnant women who do not return for
follow-up visits leading to free zidovudine therapy at 36
weeks of gestation at mother–child clinics in Abidjan,
Co ˆ te d’Ivoire, some say they refuse because they
have only heard that there is no treatment for AIDS.
They do not believe clinic staff who now tell them that
medications can protect their infants from HIV infec-
tion. This suggests that improvements are needed in
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1404
community-based dissemination of HIV prevention
information prior to pre-natal consultations. In addition
to providing accurate and up-to-date information on
prevention options, more effort is needed to integrate
prevention effort. Partners need to be aware of preven-
tion options and need to support women’s efforts to
benefit from available options. This will require VCT
approaches that are more receptive to work with both
couple members rather than approaching only indivi-
dual pregnant women as is currently the case in
antenatal settings in sub-Saharan Africa (Diaby et al.,
Community outreach is needed. The social stigma,
shame, and silence that are widely associated with HIV/
AIDS, together with the semi-public nature of many
social interactions in African communities, can create
major obstacles to efforts by individuals and couples
to seek HIV prevention information and engage in
protective actions (Caldwell, 1999). Experience of
VCT services in African countries as diverse as
Co ˆ te d’Ivoire (Coulibaly, Mselatti, & Dedy, 1996;
Diaby et al., 1996) and Zambia (McKenna et al.,
1997), and in settings as different as pre-natal clinics
and free-standing VCT centers, all indicate that
uptake of VCT services can be low despite high
seroprevalence levels in the general population. The
underutilization of HIV prevention services despite
high levels of HIV infection risk indicates that
greater efforts are needed to broaden effective access
to VCT in sub-Saharan Africa. As noted above, it
is not enough that broad-based mass media provide
HIV prevention information. Too often this information
is short on details and precludes any interaction
between providers and recipients of information. Nor,
on the other hand, is it enough for counseling staff
simply to await the arrival of clients. Improved
access to VCT in sub-Saharan Africa will require that
VCT programs, whatever their organizational setting,
reach out to the communities they serve.
Zambia and Uganda once again provide examples of
VCT programs where these complementary information
and recruitment efforts have been used to target couples.
In Lusaka, Zambia, a free-standing VCT program
undertook community outreach in an effort to increase
couples’ participation in VCT (McKenna et al., 1997).
Individuals were selected from the community, trained
for household outreach, and assigned to contact couples
in their home communities. Uptake of VCT by couples
increased after this outreach intervention. The AIDS
Information Centre in Uganda periodically advertises
special offers to couples through spot announcements on
the radio. On Valentine’s Day, for example, couples can
receive VCT for the price of one person (the equivalent
of about $3.50 US) (Elizabeth Marum, Personal
communication). In general the response is very strong
in the mother-to-child
and the number of clients can easily be twice the number
that ordinarily request VCT.
Community outreach interventions can be helpful, but
like most HIV prevention actions, they are introduced
de novo. Rarely do these arise spontaneously from
African communities affected by HIV/AIDS (but cf.
Waliggo, 2000). It can be anticipated that the accept-
ability, effectiveness and sustainability of outreach and
the behavioral and normative changes it aims to
promote will be enhanced to the degree that HIV
prevention outreach actions are linked to existing,
community-based structures for social support. Identi-
fying these support networks and developing linkages is
an area that requires more attention by both prevention
interventions and social/behavioral research in sub-
Areas where research is needed
Experiences in sub-Saharan Africa reveal that VCT
and VCT for couples in particular have a great deal to
offer current prevention efforts but numerous questions
remain. The questions are both social/behavioral and
operational in nature, and must be addressed as VCT is
scaled up in Africa. There is a need for improved basic
knowledge that has implications for the development of
prevention interventions; for example, concerning how
couples negotiate HIV risk reduction and cope during
the post-test period. Likewise a clearer picture is needed
about how interventions can enhance prevention effec-
tiveness; interventions such as community outreach,
increased recruitment of couples to VCT, specialized
counseling modules for couples, and the development of
support structures for couples during the post-test
Sexual relations and HIV risk-reduction by couples
Our understanding of sexual relations and risk
reduction with sexual partners in sub-Saharan Africa
has not improved much since 1993 when Orubuloye
and others described the lack of research on these
issues as ‘‘extraordinary’’ (Orubuloye et al., 1993).
More research is needed on risk behaviors and
risk prevention by men and women in couple relation-
ships. Factors associated with successes and failures of
couples with HIV prevention need to be studied and
Data on risk factors are commonly collected but very
little is known about communications within couples.
There is a need for both cross-sectional and longitudinal
social/behavioral studies of successful and unsuccessful
couple communications in relation to coping and HIV
prevention outcomes. Learning from the experiences of
couples over time will be essential for more effective
VCT and support interventions for couples in sub-
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1405
Gender, power and efficacy of HIV risk management by
Despite the importance of gender-related power
differences within couple relationships for HIV risk
and risk reduction (Becker, 1996; Heise & Elias, 1995;
Pivnick, 1993; Ulin, 1992; Worth, 1989), gender issues
have not been given much attention by social science
research and HIV prevention programs in sub-Saharan
Africa (Caldwell et al., 1994; Chaima & Zimba, 1998;
Ezeh, 1993; Hassoum, 1996; M’Pele et al., 1994; Mullick
et al., 1998; Obbo, 1993, 1995; Rwabukwali et al., 1994;
cf. Kashima, Gallois, & McCamish, 1992, 1993). Gender
affects communications about and negotiation of HIV
risk reduction in many important ways. Additional data
are needed on these points and need to inform VCT
interventions for couples.
Sexual violence in couples is one particularly im-
portant gender issue. Sexual violence is a multifaceted
threat to the well-being of women and their children and
a cause of fractured couple and family relationships in
sub-Saharan Africa. Social/behavioral research and
HIV/AIDS prevention interventions must give greater
attention to sexual violence in relation to HIV preven-
tion and coping by couples in sub-Saharan Africa
(Assaa Nguefack, Koua, & Kouakou, Nhaway, 2000;
Maman, Mbwambo, Hogan, Kilonzo, & Weiss, 2000;
Existing sources of support and constraints for HIV risk
reduction by couples
Likewise, attention needs to be given to the broader
social contexts within which couple members are or are
not able to protect themselves from HIV infection.
Examples include the presence or absence of support
from family, friends and other significant persons. These
support networks are an example of a diversity of socio-
cultural and economic structures of opportunity and
constraint that affect the ability of couples to benefit
from HIV prevention interventions in sub-Saharan
Africa and very little is known about them (Amaro,
1995; Bajos, 1997; Beardsell, 1994; Des Jarlais, Padian,
& Winkelstein, 1994; Farmer, Connors, & Simmons,
1996; Heise & Elias, 1995; Lurie, Hintzen, & Lowe,
1995; O’Reilly & Piot, 1996; Sweat & Denison, 1995;
Additional sources of support for coping and HIV-risk
reduction by couples after HIV testing
Operational research is needed to clarify the social-
cultural feasibility of providing additional support to
couples for HIV prevention efforts. Follow-up studies
are needed of couples with different serostatus and risk
profiles to characterize and better understand how they
cope. Information from successful and unsuccessful
cases will be useful for developing supportive interven-
tions, either as part of extended follow-up for couples,
or as separate and complementary interventions such as
support groups (Waliggo, 2000).
It is particularly important that social/behavioral
research identify strategies that couples develop them-
selves for dealing with HIV risk and the knowledge of
personal serostatus as well as the features that different
couples share in common. Information of this kind
would be most useful for ensuring that external
prevention and support interventions reinforce strategies
which, because developed by couples themselves, are
more acceptable to them.
Assessment of strategies for disseminating VCT
information to and recruitment of couples to VCT
Operational research is needed to assess effective
methods for disseminating HIV prevention information
targeted to couples. Possible approaches would include
the coordinated and complementary use of both
targeted media-based communications and more inter-
active communications with couple members using
community outreach. Despite reports during 1997 of
promising outreach efforts for couples in Zambia, VCT
programs in sub-Saharan Africa rarely include outreach
efforts to households and couples in surrounding
communities. This potentially very important compo-
nent of successful VCT for couples needs much more
VCT organization and processes: How does it work?
The sociology of VCT } of the organizational
structure and processes of VCT } has been seriously
neglected in sub-Saharan Africa. The social organization
and the professional cultures of VCT, including staff/
staff and staff/client interactions must be better under-
stood before improvements can be effected in VCT
Outcome successes and problems
Are successful (and unsuccessful) coping and HIV risk
reduction outcomes of VCT for couples attributable to
particular staff actions, program policies, or are post-test
successes and failures chance occurrences? Operational
research on recurrent success and problem cases is
needed to complement program evaluations and to
identify personal and organizational features associated
with successful and unsuccessful social/behavioral and
biomedical outcomes among couples.
Social impacts of VCT
While VCT programs target individuals and occa-
sionally couples, their actions may gradually contribute
to a critical mass in surrounding communities because of
the presence of persons who have accepted or refused
HIV testing and have gained some familiarity with VCT.
This critical mass of persons and of shared experience
and knowledge, may result in broader social impacts,
T.M. Painter / Social Science & Medicine 53 (2001) 1397–1411 1406
including changes in community values and norms that
affect persons beyond those who have participated
directly in VCT. Examples of change include greater
communication and openness in everyday life about
HIV prevention and the advisability of risk-reduction,
decreased denial about the existence of AIDS, enhanced
understanding and acceptability of available prevention
options, including VCT, greater acceptance of and
support for persons who have been tested for HIV and
greater support for disclosure of HIV test decisions and
test results. The broader social impacts of couples-
focused VCT are of particular significance given that,
first, the salience of couple relationships to heterosexual
transmission of HIV infection in sub-Saharan Africa
and second, the obstacles that couples often face with
communicating about sexuality and about HIV risk
reduction. To date the broader social impacts of VCT
beyond the outcomes recorded for individual or couple
VCT clients have been ignored in sub-Saharan Africa.
This paper has provided a brief overview of results
from recent research and HIV prevention interventions
in sub-Saharan that focus on couples and HIV risks,
VCT, and in particular, VCT for couples. It has been
proposed that the growing body of research and
program evidence from sub-Saharan Africa which is
supportive of VCT for couples as a HIV prevention tool,
together with an increasingly supportive international
policy environment for VCT, have created a unique
sociological conjuncture for HIV prevention in Africa.
In effect, developments in research, interventions and
policy have brought us back to basics of HIV prevention
that have been neglected for too long by social/
behavioral research and prevention interventions in
Africa: couple relationships. This conjuncture reveals a
need for change in prevention paradigms to ensure a
better sociological fit between how persons in Africa
confront and deal with HIV risks on the one hand, and
on the other, how prevention interventions that aim to
support prevention actually focus their attention and
resources. More work with couples promises to enhance
the already promising potential of VCT for HIV/AIDS
prevention sub-Saharan Africa.
The author wishes to thank Carl Campbell, Tim
Dondero, Lynda Doll and several anonymous reviewers
for their helpful comments on earlier drafts of this
paper, however the author accepts sole responsibility for
the form and content of the current version. The views
expressed herein are those of the author alone and do
not necessarily reflect those of the Centers for Disease
Control and Prevention.
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